Nursing Holes

Colorado Public Radio (CPR) reported ten days ago that the U.S. Department of Justice “has complained that Colorado violates federal law by not providing adequate services to transition people with physical disabilities out of nursing homes and back into the community.” It was the following statistic, however, that startled me: “From 2013 to 2019, only 269 Coloradans with physical disabilities transitioned from nursing facilities to the community, according to a multi-year review by the Justice Department.” That’s less than forty people a year and a little more than one per the 231 facilities in the state over those seven years.¹ The implication is that nursing homes are warehousing people.

I know from personal experience that this is a reasonable conclusion, but the problem is more complicated than it sounds. Nursing homes are one part of a system full of holes.

Care or Curb?

The plight of an old friend—we’ll call him John—is a case study in this system. In October of 2019 John had a stroke, which landed him in a Denver area nursing home. My wife Andrea Carney and I didn’t locate him until January 2020. It became clear that John might be thrown off public health care if I didn’t intervene on his behalf. On February 28 he granted me power of attorney (POA).

The nursing home business office staff were helpful. They had successfully gotten John’s Social Security check for March deposited in his nursing home trust account. By law, the home takes the first 87%.

On March 3, they told me John was in arrears and gave me a statement for his “share of cost” for November through February. I paid them with a check from his bank—we’ll call it Wells Fargo (because it was). I gave them his bank statements to use in getting his Medicaid reinstated; he’d been denied on February 3, after three months of emergency coverage. On March 9 they called again asking for his statements. I told them I’d already delivered them.

On March 11 WHO declared Covid-19 a pandemic. Two days later—Friday the 13th—I visited the nursing home to give John a tiny birthday cake and card. After being screened for Covid-19 for the very first time and being given my very first mask, I was told I couldn’t see him. I believe that even by then nursing homes had become Covid factories. John eventually would contract it there. As the CPR story above mentions, “A CPR News investigation last year found that at one point Colorado led the nation in the nursing home death rate.”

I was allowed to see the business office staff. They suggested John close out his bank account to simplify asset reporting in order to get his Medicaid reinstated. I cleared this with John (by phone!) and went to Wells Fargo with my mask. The tellers laughed when I showed it to them. “I don’t think we’ll ever wear those here,” one told me. Returning to the business office, I gave them the closeout check for deposit in his trust account along with proof of the account’s closure.

On about Thursday, March 26, the business office told me that the government somehow had a record of John’s Wells Fargo savings account. Proof of its closure was the last document needed to reinstate his Medicaid. The bank told me by phone that the account had been closed but I had to visit a branch to obtain proof. I did so and was told that because I didn’t have power of attorney when the account was closed in 2019 I’d have to subpoena the bank’s record. I was furious and stormed out of the branch.

On Friday I called Colorado Legal Services (CLS) to see if they could help with John’s Medicaid. They were very efficient and worked with me over the weekend. And for them the term emergency actually had meaning.

On Monday the 30th I took a deep breath and went back to Wells Fargo. Andrea and I have a history with the institution. At one point we had a WF credit card onto which was attached a credit insurance policy of some sort that we’d never approved. We had our Denver mortgage ported over to WF without our desire, but resisted refinancing because it’s expensive. During the heyday of Occupy Denver we were informed that WF invests in private prisons. The camel’s back broken, we took our business elsewhere. (See this Wikipedia list of twenty-five WF Lawsuits, fines, and controversies.)

This time at that same WF branch I was helped by an agent who consulted with their local supervisor rather than a remote advisor. I received the proof of closure in minutes. I called CLS to say I no longer needed their services. Not so fast, I was told, It ain’t over ’til it’s over. And it wasn’t. On Tuesday CLS noticed John’s Medicaid denial appeal had to be filed by Wednesday, April 1, which they did.

The clock ticked by and CLS wondered why the delay with Medicaid. Shortly before 10 a.m. on April 16 CLS requested and received a copy of the email the business office had sent the Denver government on March 31 with the “last document needed for John’s Medicaid.” Twenty minutes later CLS noticed a typo in the government email address and resent it; the government rep agreed to proceed as if that doc had been received on the 31st. At 2:16 that same afternoon we received John’s Medicaid approval letter.

At some point I asked the nursing home business office what would have happened if we hadn’t been successful. Essentially John would have been shown the curb. Well, that’s one way of transitioning to the community.

Ironically, at about this time, the nursing home’s social worker offered that they felt John was a candidate for actual transition. John agreed and we got the ball rolling.

A Two-Year Transition

Transition agency reps reached out to John twice by phone. Both times we were informed by the nursing home social worker that John had told the rep he didn’t want to leave. Each of John’s “refusals” caused his transition case to be restarted from square one. The third time was a charm. About a year after John’s initial contact with the transition agency, I and John’s medical POA, who knows assistance programs better than I do, felt left in the dark regarding progress. On March 23, 2021, at a care conference with nursing home staff, we asked to be put in contact with John’s transition coordinator. We’ll call her Rose.

Because John would be essentially indigent upon transition, Rose needed to qualify him for a Section 8 voucher to supplement his rent. Just as with Medicaid John had to verify his income. On March 29 Rose asked for John’s Social Security “award letter.” I explained that I’d sent John’s annual SSA-1099 Social Security Benefit Statement to the nursing home social worker on February 15 and they’d acknowledged receipt a week later.

On April 19 Rose asked for new copies of John’s photo ID, birth certificate, and SocSec card. I had access to the latter two, but we accidentally copied John’s expired ID, still in his wallet. On April 22 we forwarded the correct docs. On May 19 Rose asked for the SocSec award letter again. I told her I sent it in February. She told me they needed one for May. She explained that this required calling the SSA.

Beginning on May 20, in half a dozen conference calls with SSA, John and I asked for the award letter but never received any. Just as with Wells Fargo we were at the mercy of individual reps who could be either accommodating or anal-retentive. Either way, it didn’t get us any further. We even visited a local office, but a security guard barred the door; the office was closed due to Covid. From the parking lot we asked an agent at that office by phone if they could scoot the letter under the door. No; it was placed in the mail, and like the others it never arrived. Finally we asked for a face-to-face meeting. The. Clouds. Parted. “We can fax it.” I ran by the nursing home, picked up the fax, scanned it, and sent it to Rose. This was July 27, 2021. It had taken nearly ten weeks. (Two letters did arrive, but after we received the fax.)

The week of August 8 John’s disability documentation was forwarded from the nursing home to Rose, who then submitted his voucher application. On August 26 the voucher was approved. A voucher orientation was scheduled for September 9, but as of the 8th John hadn’t been informed by the nursing home. Rose did visit John in the nursing home on the 9th and the session was conducted remotely. Rose would look for an apartment on her end but she encouraged us to look as well. John had 120 days to secure housing before the voucher expired.

Four months may seem like a lot of time, but the housing market in Denver is tight and not all landlords accept vouchers. Rose told us about a 62-and-up high rise and we emailed the application on September 30, but as of October 6 the manager hadn’t received it. I sent a duplicate and we brought a hard copy when we toured the building on the 12th. Of course John had lost his place in line. He also required an ADA-compliant unit, which reduced his options.

On December 1, John finally received word from the building manager that a unit had opened up, but Denver Housing Authority had to approve the lease and had to inspect the unit. None too soon. John’s voucher would expire on about January 7.

John finally was discharged from the nursing home on February 9, 2022, nearly two years after the social worker first suggested transition, and moved into a studio apartment. He opened a bank account on the 22nd but they held his deposit until March 4—well after his rent was due on the 1st. Social Security tried to deposit his March check at the nursing home even though he’d been gone three weeks. The bank claimed the check had been deposited there, but when John went in on the 9th the money wasn’t there. Enraged, he closed his account. And it wasn’t even Wells Fargo.

Only the “Really” Needy Will Apply

Last week, on March 10, NPR reported on the federal child tax credit, which ended in December. The report contained interesting analysis. When host Sarah McCammon noted that the tax credit program had no requirements other than having at least one child, economist Elizabeth Ananat from Barnard College replied:

The sort of historical notion had been if we put up a lot of hurdles to getting benefits, then only the people who really need them will be willing to fight through those hurdles. And that way, we’ll sort of save money because we won’t spend it on the people who don’t really need it because they won’t bother. And we’ll just get it to the people who really are needy and sort of deserving.

You actually end up with those approaches backfiring where it’s actually families who need help the most who don’t have the resources to navigate those hurdles. And they’re the ones most likely to be left out of these programs. And so this was a big change because the idea was we’re going to try to make it be as low-hurdle as possible. You just need to have kids, and we will send you the check. And that way, we’ll get the money to everybody. And in particular, we will get it to the families that need it most.

John faced hurdle after hurdle. And he really needed the programs he accessed.

To this Ananat added:

Well, I think one of the most important things we learned is that there was no effect on parent work. You know, this is research that we’ve done where we pushed and pulled on the data every which way trying to see if we could find some parents dropping out of the labor force because now, you know, they have this money, whether they work or not. And we just saw no evidence of that at all. And this had been a thing that really, I think, held policymakers back from providing this type of assistance – was the fear that it would lead to lower parent work. And we just don’t see that at all. And I think now that we can see that that really just did not happen, people can proceed with a lot more confidence. And this is a great way to help families, and it won’t have these unintended side effects.

Staff turnover, on the other hand, has been a major issue during the pandemic, as we all know. At John’s nursing home the business office staff were pulled out to work the reception desk and even deliver residents’ meals. (This had a side benefit of bringing that staff into more contact with the residents.²) Quite cheerful in January 2020, I detected stress on their part as the pandemic progressed.

Both workers in the business office left John’s nursing home. The cover story in yesterday’s Denver Post states, “Of the 183 Colorado nursing homes with data on Medicare’s Care Compare website, 123 saw at least half of their staff turn over in the last year.”

But At Least We’re Free…

In December, as the child tax credit was to expire, President Biden signed a $770 billion military spending bill—$25 billion more than he asked for. Lots of enhancements for soldiers, including a 2.7% pay raise. And yet a disabled person like my friend John—a veteran himself—can come inches from being kicked to the curb.

Header image:
“John” on the phone
with us during lockdown,
22 May 2020, with Andrea’s
houndstooth reflected in window

Notes

1. See the Quarterly Census Report at Colorado DPHE for the number of homes operated in Q3 2019.
2. Taking on multiple duties is a hallmark of the Participatory Economics model’s Balancing Jobs.